RESEA R C H Open Access Social structural factors that shape assisted injecting practices among injection drug users in Vancouver, Canada: a qualitative study Nadia Fairbairn 1 , Will Small 1 , Natasha Van Borek 1 , Evan Wood 1,2 , Thomas Kerr 1,2* Abstract Background: Injection drug users (IDU) commonly seek manual assistance with illicit drug injections, a practice known to be associated with various health-related harms. We investigated the social structural factors that shape risks related to assisted injection and the harms that may result. Methods: Twenty semi-structured qualitative interviews were conducted with IDU enrolled in the ACCESS or Vancouver Injection Drug Users Study (VIDUS) who reported requiring assistance injecting in the past six months. Audio-recorded interviews were transcribed verbatim and a thematic analysis was conducted. Results: Barriers to self-injecting included a lack of knowledge of proper injecting techn ique, a loss of accessible veins, and drug withdrawal. The exchange of money or drugs for assistance with injecting was common. Harms experienced by IDU requiring assistance injecting included theft of the drug, missed injections, overd ose, and risk of blood-borne disease transmission. Increased vulnerability to HIV/HCV infection within the context of intimate relationships was represented in participant narratives. IDU identified a lack of services available for those who require assistance injecting, with notable mention of restricted use of Vancouver’s supervised injection facility. Conclusions: This study documents numerous severe harms that arise from assisted injecting. Social structural factors that shape the risks related to assisted injection in the Vancouver context included intimate partner relations and social conventions requiring an exchange of goods for provision of injecting assistance. Health services for IDU who need help injecting should include targeted interventions, and supervised inject ion facilities should attempt to accommodate individuals who require assistance with injecting. Introduction The injection of illicit drugs is a growing public health concern internationally, and human immunodeficiency virus (HIV) transmission among injection drug users (IDU) represents a significant factor driving the global HIV epidemic. There are an estimated 16 million indivi- duals who inject illicit drugs worldwide and 3 m illion injectors living with HIV [1]. Even in settings where a comprehensive public health response to injection drug use has been implemented, including needle exchange and health outreach programs, IDU continue to be exposed to a range of drug-related harms [2,3]. Recent studies have demonstrated that, even when ster- ile needles are accessible, individual characteristics and social structural factors may make IDU vulnerable to syr- inge sharing and subsequent HIV infection [2,4]. R hodes’ risk environment framework has identified a host of fac- tors beyond the individual level that shape drug injecting practices and has illustrated how social context influ- ences the production of injection-related HIV risks [5]. Social structural factors that may compro mise individual ability to employ HIV prevention strategies among IDU include the influence of extended peer networks [6], as well as prevailing social norms among local populations of IDU [7]. Situated cultural norms have been shown to be particularly significant in shaping local and context- specific drug use risk practices, including routes of administration and"rituals” of use including drug pro- curement, exchange, and sharing [8]. Ethnographic * Correspondence: uhri@cfenet.ubc.ca 1 British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, B.C., V6Z 1Y6, Canada Full list of author information is available at the end of the article Fairbairn et al. Harm Reduction Journal 2010, 7:20 http://www.harmreductionjournal.com/content/7/1/20 © 2010 Fairbairn et al; lice nsee BioMed Central Ltd. This is an Open Access arti cle distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. research has highlighted the importance of the “cultural logics” of the street economy [9,10], as well as the gen- dered dynamics that often surround the injection process [11,12], as contextual factors that compromise individual ability to enact risk reduction strategies. Previo us work has indicated that a substantial propor- tion of ID U in various settings internationally receive manual assistance with injections [13,14]. The role of ‘hit doctor’ (i.e., someone who provides assistance with injections) was first described by Murphy (1991) who observed that experienced injectors working in shooting galleries in the San Francisco B ay area often provided assistance with injecting in exchange for money [15]. In Vancouver, Canada, a city with high rates of injection drug use and HIV among IDU, nearly half of local IDU have reported receiv ing assistance with injecting in the previou s six month period [16]. In th is setting, receiving assistance with injecting has been identified as a strong independent predictor of syri nge sharing and HIV sero- conversion, with IDU who report this behaviour being twiceaslikelytoacquireHIVincomparisontoIDU who do not require assistance injecting [16,17]. Assisted injection has also been associated with non-fatal over- dose among IDU in Vancouver [18]. Given that assisted injection is a highly prev alent prac- tice known to be associated with severe health complica- tions in our setting, including HIV infection and overdose, we conducted a qualitative study to explore the circum- stances and social conventions surrounding assisted injec- tion. We sought to pay particular attention to individual factors as well as the broader contextual forces that shape the experience and harms of assisted injection. Methods This article presents analyses of data from qualitative interviews with Vancouver IDU who require assistance injecting. One-to-one in-depth interviews were con- ducted to explore the following topics: 1) injection- related knowledge and practices; 2) experiences of assisted injection; 3) the broader context of assisted injection, and 4) harmful experiences resulting from assisted injection. We draw upon data from 20 in-depth qualitative interviews conducted during June and July, 2007. Inter- viewees were recruited from two cohort studies in Van- couver: the Vancouver Injection Drug Users Study (VIDUS), which is composed of over 1000 HIV negative IDU; and ACCESS, which is composed o f over 500 HIV-positive IDU. Database markers were used to iden- tify participants from these cohorts who reported receiv- ing assistance with injecting. Given the large representation of female IDU requiring assistance inject- ing in our setting [13,17], attempts were made to recruit female IDU for the present study. Interviews were undertaken by three different trained interviewers ( Fairbairn, Van Borek, and Small) and facilitated through the use of a topic guide encouraging discussion of assisted injection. Interviews lasted between 30 and 60 minutes, were tape-recorded, and were later transcribed verbatim. The research team dis- cussed the content of the interview data througho ut the data collection process, thus informing the focus and directio n of subsequent interviews as well as deve loping a coding s cheme for partitioning the data categorically. The content of transcribed interviews was catalogued using a coding f ramework specific to assisted injection and our ana lysis explores themes that emerged through- out the interviews. Two members of the research team (Fairbairn and Borek) separately catalogued the tran- scribed interview data using a coding framework, thus allowing for discussion of areas of agreement and instances of divergence. All participants in the qualitative study provided informed consent to participate, and the study was undertaken with appropriate ethical approval granted by the Providence Health Care/University of British Colum- bia Research Ethics Board. There were no refusals of the offer to participate in the interview and no dropouts during the interview process. All interviewees received CDN$20 for their participation. Results The study sample consisted of 20 participants, (7 male and 13 female) who ranged in age from 24 years to 51 years (median age = 40). Participant accounts described the potential barriers to self-injectio n, namely lack of knowledge of injection techniques or difficulty accessing veins due to long- term injecting. Social and structural factors that shape risk among IDU who require assistance with injecting were described by parti- cipants, including intimate partner relationships as well as the drug scene role of ‘hit doctors’ that require an exchange of goods for the provision of assistance inject- ing. Numerous harmful experiences that can result from assisted injection, namely increased risk for overdose and infecti ous disease transmission, were represented in participant narratives. One significant barrier to acces- sing care and support described by participants who require assistance with injecting was the rule prohibiting assisted injection at Vancouver’ssupervisedinjection facility (SIF). 1. Injection-Related Knowledge and Practices a. Reasons for Requiring Assistance with Injecting The accounts of interview participants indicate that sev- eral barriers prohibit individuals from being able to self- inject. Several participants described requiring assistance with injections because they lacked the injection-related Fairbairn et al. Harm Reduction Journal 2010, 7:20 http://www.harmreductionjournal.com/content/7/1/20 Page 2 of 7 knowledge necessary to self-inject, particularly at the time of their first injection. I was thirteen years old and I was running away from a group home. And my best friend, we were watching her cousin, and taking license plates, for when she was working on the street. So at the end of the night, we go b ack to her hotel room and she would shoot us some coke, for taking license plates and that So she would fix herself a nd then she would fix me. (Female Participant #19) Individuals described a loss of accessible veins, due to long-term injecting, as another key barrier to self-injection. Well, it’ sveins,Ihavenoveins.It’ s all collapsed, or calloused So there are times I can, every once in awhile a vein will pop up, and then I can use it for a few times, and then it will go back down If I can’t get it in two or three times, there’s somebody I know, you know he can get me in the arm or in my neck. (Male Participant #6) Several participants described requiring assistance injecting due to collapsed veins and choosing to “ jug” (inject in the jugular vein) in these instances. I: You do mostly your own injections? R:Ah,actuallymyboyfrienddoesitnow,because sometimes I’ m having a hard time with my arms now, because of all the injecting I did. Having to find a vein, he jugs me now { } Yeah, I can’t find, like you know just can ’t find any veins sometimes, so he’ll go in the neck for me, or I go myself in the neck. (Female Participant #2) Some participants required assistance with injecting on occasion while experiencing symptoms of shakiness or feelings of anxiety, such as during instances of drug withdrawal. Well I’ mjustbeing,I’ m just being really anxious lately. I don’talwaysneedhelp,butIjustwantto have that hit. I want to have it I don’t want to fuck around anymore, my veins are pissing me off. (Female Participant #9) One participant described his inability to self-inject due to a physical disability that prohibited him from using one of his arms. My brother, my best friend, usually ties me off and does it because I have a disability I can’t because of the handicap. (Male Participant #14) Within the context of intimate par tner relationships, several female parti cipants described assisted injecti on as a way to demonstrate trust and intimacy in addition to a form of n eeded assistance owing to a lack of injec- tion-related knowledge or technique. Yeah my partners have all you know they fixed right. And usually they it’ s a trust thing again. Kind of the more you know a person, then they know your body, how your veins are and stuff right. So it just works better that way it seems right, you know. Yeah, yeah and having that bond is also spe- cial too, which is cool. You know like you care, right, you don’twanttohurtthem,youdon’twant them to get hurt you know?{ } Yeah, but usually, it’ s, my boyfriend w ill do both of us or whatever, yeah.{ }If he’s a little sick, he might do himself first or whatever. But usually, I go first. (Female Partici- pant #16) I: The only person you ever had jug you was your husband? R: Yeah, and then I’d do it for him. I: He also had trouble with his veins? R: Ah no, it was just that it was easier for me to do it for him, because I was already high, and he wanted to be high at the same time as me, so he’d fill it out, and I’ d get high, and do him right away. (Female Participant #10); b. Exchange for Assisted Injection Services Participants described the provision of assisted injection services as a well-established role within the street econ- omy that typically involves an exchange of money or drugs. R: If they’ re going to fix me with a ten paper of powder, I’d shoot them five bucks. I: Okay and always you give something? R: Always It’ s kind of like a cardinal rule down here. (Female Participant #19) The amount of money or drugs exchanged for help with an injection varied and was negotiated between individuals. One participant described a willingness to pay more money when feeli ng a greater s ense of urgency to use drugs. He likes his rock. I’ll give him the money to go buy it, or I’ll just give it to him. I mean, he doesn’taskfor it If I want to get high real bad, it’s worth a lot { } once I get it in me, and I get the rush, it’ s worth a million dollars. (Male Participant #6) Participants described the harms that can arise when ‘hit doctors’ have material incentive to help someone Fairbairn et al. Harm Reduction Journal 2010, 7:20 http://www.harmreductionjournal.com/content/7/1/20 Page 3 of 7 inject and may lack concern for preserving the safety of the individual they are injecting. It’s [assisted injection] pretty risky, because you really don’ t know, they could be bullshitting you right? Because just to make that extra dollar or whatever (Female Participant #4) Because of this risk, participants emphasized the importance of having a trusting interpersonal relation- ship with a ‘hit doctor’. I’ve had people that like, ok, like, last night, I said" M Ineedyourhelp.” He goes"What’ sinitforme?” I said” Absolutely nothing” until today and then I get him back. But a lot of times, they see if they’re being paid for it { } But anyways last night I was saying,"Ineedyou,andIknowyoucandothis,but how are you feeling"? He’s got ba d eyesight, and he can’ t buy glasses but I trust him, the trust factor is first. And then it’s the physical, could he do it and see it? (Female Participant #9) 2. Harmful Experiences Due to Assisted Injection Participants identified several potential harmful out- comes that can arise from relinquishing control over the injection process. These included missed injections and consequent health problems, robbery, infectious disease transmission, and overdose. a. Missing the Injection A variety of health complications including abscess for- mation and other forms of infection can result from missed injections. The most harmful complications of missed injections described by participants involved jugular injection, where the carotid artery, jugular vein, trachea, and recurrent laryngeal nerve are in close proxi- mity to the point of the syringe [19]. Yeah, missing my shot in the neck. Th at was the scariestpart,itwaslikeasharppainrightuptomy head, and I was numb on t his side for the longest time. { } He just missed me, and I don’t know, must have hit a, I don’ t know, he hit something I got scared, like I thought I was going to be gone or some- thing, you know. (Female Participant #4) The worst experience I had was before I got the abscess at the back of my throat, when somebody was jugging me, and somebody kicked the fucking, kicked me while I was getting jugged.{ } And then so two days later, an abscess formed in the back of my throat, right here. { } and I almost died because it formed so fast, and so quickly. { } and it was starting to block my swal- lowing, and my breathing. (Female Participant #9) b. HIV/HCV Transmission Having one’s syringe unknowingly exchanged (by the person providing assistance with injecting) for another containing only water was reported by numerous parti- cipants. In addition to theft of the drug, concern was expressed about receiving an injection with a syringe of unknown origin. Actually it was my boyfriend too. When he was a heroin addict he was really bad. [ ] Yeah he, I asked him to fix me, like I had heroin for sale, and he was holdingmydopeforme,andIaskedhimtofixme up one, { } and there I could see him shaking some- thing, he was putting water in it { } I busted him right, he was going to switch me. Yeah. And he got really mad and threw my rig, and threw my d ope across the street because I busted him. He was going to gypsy switch [swap rigs for one filled with water] me. (Female Participant #4) Many IDU described relying on a ‘hit doctor’ to pro- vide injection equipment in addition to administering the injection, resulting in vulnerability to HIV and other infectious diseases. I: Is there anything else that you worry about when you’re going to have someone else fix you? R: Well not just about them switching rigs, but you don’t know if the rig that they’re giving you has HIV in it or not. { } Well, yeah, like two weeks ago I fixed with a rig that had blood in it just because I was that dopesick. (Female Participant #19) Syringe sharing between intimate partners who pro- vide assistance injecting one another was a potential route of infectious disease transmission described by several participants. R: When I first started fixing heroin. Yeah my boy- friend would jug me and that , we had this big can- ister. We’ djustthrowourusedrigsinthereand usually when we’d wake up, if we were do pesick, we would just grab any rig out of the container. I: Okay and so, would you usually get injected first? R: No, he would do h imself first and then me. (Female Participant #19) When I had a boyfriend he used to inject me, but he used to do bad things though, change the needles and stuff especially in my neck, he’d just push it in, in my neck went like this, you k now, but he’ d switched the rig I got Hepatitis C from him, ‘cause he gave me his bloody fix one time, that’showIgot Hep C. (Female Participant #5) Fairbairn et al. Harm Reduction Journal 2010, 7:20 http://www.harmreductionjournal.com/content/7/1/20 Page 4 of 7 c. Overdose Accidental overdose was commonly reported. Several participants described incidents that involved misco m- munication over the amount of drug to be injected which lead to overdose. I used to throw the whole half a gram in the spoon right, but I mixed up rigs, different rigs for each amount, like 20 units in each one. I threw a half i n there, and I turned my back, thi s other guy threw a ¼graminthereandIdidn’t know about it Boom, he fixed m e, I g ot half way and I told him to sto p, stop. I said,"No, no, don’ t do that”.Hewasgoingon and on and he said,"It’ sokay,I’ m almost there”.I said,"No, no wait a minute”. And boom, he pushed it in. I sta rted vibrating, I wa s feeling like, Holy Sh it. And I’ mgoing"Oooh”.LikeI’ m really starting to spin and everyth ing. He’s goi ng,"are you okay”.Isaid,"I’m okay, just don’ttouchme”. He said,"No, no you need to get up and walk”. And he grabbed me by the arm andpulledmeup.Itooktwosteps,andeverything went white. (Male Participant #3) This one girl she didn’t tell me not to push it all in. So I smashed it all in and right after, before I pulled the needle out, she goes"You weren’t supposed to put it all in” and then just, she just turned into like a robot. She was like, she started running, blindly, running in to telephone poles, running into walls, into everything and just, holy smokes, I couldn’t believe what was going on. (Female Partici- pant #19) 3. Barriers to Injecting at the SIF A number of participants described the rule prohibiting assisted injection at Vancouver’ s SIF as a barrier to engaging in safe injecting p ractices. The SIF is a place where IDU c an inject pre-obtained illegal drugs u nder the supervision of nurses trained to provide an emer- gency response in the event of overdose. Presently, only verbal direction and limited manual assistance (exclud- ing the act of injecting) is permissible f rom staff. Some participants noted that this assis tance enabled them to administer their own injection, while others were still unable to self-administer their injection. Many of these individuals reported that they had to then leave the facility to find another ID U in the nearby alleys to assist with the injection. I: Have there ever been times when you’ve needed to get some help with an injection, and you couldn’ t find somebody to help you out? R: Yeah. I had to really take my time to, I had to get Insite to help me, to direct me, because I couldn’ t find nobody else that was safe. { } Yeah, I had to do it myself and eventually, I got it. { } They just direc- ted me, l ike you know, like telling me which way to go. { } Yeah, they talked me through it. I: Have y ou ever gon e in t here to fix , and t hen not been able to get it done yourself? R: Yeah, I have. Go outside and see somebody there to jug me, yeah, that has happened. (Male Partici- pant #2) R: Like actually last night, it was so weird, I go, ‘Well, I’m going to go inject, and then come back in here [InSite]’.It’s because I hadn’t been able to inject myself properly, and so I needed somebody to jug me and you can’ tgetanyassistanceatallandsome- times I just can’ ttakethetimeoutwithmyself, I can’t be with myself enough to actually inject myself properly and fast. Like ‘cause I want to get it in me too fast, I get too anxious, ‘ get in’ . And now, that’ s why I end up with shit like this [injection-related infection] on my arm, right? (Female Participant #4) Some individuals reported that they would not use the SIF because of the rule prohibiting assisted injection. I: What about that rule at INSITE where you ca n’t get help with an injection? R: That’s the reason why I won’t go there. I think that sucks. That, it’ s not good, it’s, they should do s ome- thingaboutsomethinglikethat.‘ Cause what hap- pens if I want to go in there, and need help and nobody will help me? Well what’sthisplaceherefor then? (Male Participant #5) Discussion We identified a range of individual, social, and structural factors that shape the context of risk associated with assisted injection. The perspectives of participants in the present study highlight several barriers to self-injection, including lack of injection-related knowledge and tech- nique, inability to access veins due to long-term inject- ing and physical disability. We documented a variety of harms that can result from relinquishing control over the injection process and identified various social factors that shape these harms, including intimate partne r rela- tions and social conventions requiring an exchange of goods for provision of injecting assistance. The rule pro- hibiting assisted injection at Vancouver’s SIF was identi- fied as a structural barrier to receiving injection-related instruction and support. Participant accounts detailing assisted injections high- light the difficulty in ensuring that a syringe is steril e when obtaining assistance with injecting, and may help shed light on previous work that has found the charac- teristic of requiring assistance with injecting to be an Fairbairn et al. Harm Reduction Journal 2010, 7:20 http://www.harmreductionjournal.com/content/7/1/20 Page 5 of 7 independent predictor of HIV seroconversion [17]. Sev- eral participants in the present analysis described bor- rowing syringes and injection equipment from the ‘hit doctor’ when receiving assistance with injecting. These descriptions may help expl ain findings from previous research indicati ng that requiring help injecting is inde- pendently associated with reporting borrowing aused syringe a nd providing assistance injecting (e.g., being a ‘ hit doctor’) is independently associated with lending one’s own syringe [13,19]. Switching of syringes by the ‘ hit doctor’ in order to steal drugs was commonly reported, and represents one important route by which HIV transmission may occur for individuals who receive assistance with injecting. Additionally, the finding that miscommunication and confusion surrounding the quantity of drugs administered may occur during assisted injections helps shed light on the previous epi- demiological findings indicating that this practice is also associated with non-fatal overdose. Narratives from several female participants portrayed assisted injection as an opportunity t o share in the injecting process and drug high, thereby fostering an increased sense of trust and intimacy. Assisted injection as a symbolic act in the context of intimate relationships may therefore represent an important point of intersec- tion of sexual and injecting dynamics, comprising a"dual risk” for HIV acquisition [20]. Previous qualitative work has investigated the gendered dynamics surrounding assisted injection by documenting women’s experiences of theft and violenc e, including e xperiences of abuse from intimate partners when being injected with illicit drugs [12,21] . Though no such accounts were documen- ted in our study, the gendered dynamics of assisted injection begs further exploration given that women are twice as likely as men to report requiring assistance with injecting in our setting [13,17]. IDU who require assistance with injecting unani- mously reported an exchange of money or drugs in return for the provision of injecting assistance. This exchange of resources situates assisted injection services within the street economy and introduces the possibility of harm in instances where ‘hit doctors’ provide assis- tance with injecting purely for lucrative benefit [14,15]. This exchange-for-service dynamic may further exacer- bate harms for IDU who require assistance with inject- ing by increasing the likelihood of violence resulting from disputes over compensation given the lack of an authority to resolve such disputes. Vancouver’s drug policy response to the ongoing HIV epidemic has involved the implementation of numerous harm reduction strategies including needle exchange programs, a heroin maintenance trial, and a SIF [22]. A current limitation of many SIFs, including the one in Vancouver, is that operational guidelines prohibit assisted injections on th e premises due to concerns over civil liability should assisted injections be permitted within S IFs [23,24]. However, given the significant bar- riers to accessing care an d the increased risk of HIV infection for individuals who require assistance with injecting, we recommend reconsideration of this policy. Indeed, a previous study of an unsanctioned drug-user- run SIF documented the successful implementation of an assisted injection policy, which resulted in many indi- viduals developing the competency to self-inject [25]. The present study has several limitations that warrant acknowledgement. Firstly, our findings are based upon interviews with lo cal IDU pa rticipating in the current study. While an eff ort was made to ensure that th e study sample reflects the demographics of the local drug-using population who require assistance injecting, some perspectives may nonetheless be underrepresented. Secondly, as injection drug use is a highly stigmatized behaviour, it is possible that social desirability bias affected the responses of some participants. Thirdly, the data collected and analyzed here presents only the view- points of IDU; the results of this analysis should be compared with the findings of ethnographic research utilizing participant-observation within the SIF. In summary, we found that ba rriers to self-inj ecting included a lack of knowledge of injection practices, symptoms of anxiety or withdrawal, or a loss of accessi- ble veins. Our qualitative data indicate that numerous harms can result from the practice of assisted injection, notably increased risk for infectious disease transmission and overdose. Some women reported a preference to have a partner inject in order to develop trust and inti- macy, underscoring the importance of considering social and contextual factors when examining infectious dis- ease transmission among IDU. Participants identified the rule against assisted injection at the SIF to be a sig- nificant barrier to accessing health care, a nd therefore this policy should be re-evaluated. Acknowledgements We would particularly like to thank the VIDUS and ACCESS participants for their willingness to be included in the study, as well as current and past VIDUS and ACCESS investigators and staff. We would specifically like to thank Deborah Graham, Tricia Collingham, Caitlin Johnston, Steve Kain, and Calvin Lai for their research and administrative assistance. The authors also wish to thank the staff of Insite, the Portland Hotel Society, Vancouver Coastal Health (Chris Buchner, David Marsh, and Heather Hay). This study was supported by Canadian Institutes of Health Research (CIHR) grants MOP- 81171 and RAA-79918. Will Small is supported a Michael Smith Foundation for Health Research (MSFHR) Senior Graduate Studentship and a CIHR Doctoral Research Award. Thomas Kerr is supported by the Michael Smith Foundation for Health Research and the Canadian Institutes of Health Research. Author details 1 British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, B.C., V6Z Fairbairn et al. Harm Reduction Journal 2010, 7:20 http://www.harmreductionjournal.com/content/7/1/20 Page 6 of 7 1Y6, Canada. 2 Department of Medicine, University of British Columbia, 10203- 2775 Laurel Street, Vancouver, B.C., V5Z 1M3, Canada. Authors’ contributions NF and TK were responsible for the study design and prepared the first draft of the analysis. 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Four Pillars Coalition: Four Pillars: Four Years. Where to Now? Book Four Pillars: Four Years. Where to Now? Vancouver Drug Policy Program, City of Vancouver 2005. 23. Pearshouse R, Elliot R: A Helping Hand: Legal Issues Related to Assisted Injection at Supervised Injection Facilities. Toronto: Canadian HIV/AIDS Legal Network 2007. 24. Kerr T, Wood E, Small W, Palepu A, Tyndall MW: Potential use of safer injecting facilities among injection drug users in Vancouver’s Downtwn Eastside. CMAJ 2003, 169:759-763. 25. Kerr T, Oleson M, Tyndall MW, Montaner JS, Wood E: An evaluation of a peer-run safer injection site for injection drug users. J Urban Health 2005, 82:265-275. doi:10.1186/1477-7517-7-20 Cite this article as: Fairbairn et al.: Social structural factors that shape assisted injecting practices among injection drug users in Vancouver, Canada: a qualitative study. Harm Reduction Journal 2010 7:20. Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit Fairbairn et al. Harm Reduction Journal 2010, 7:20 http://www.harmreductionjournal.com/content/7/1/20 Page 7 of 7 . RESEA R C H Open Access Social structural factors that shape assisted injecting practices among injection drug users in Vancouver, Canada: a qualitative study Nadia Fairbairn 1 , Will Small 1 ,. this article as: Fairbairn et al.: Social structural factors that shape assisted injecting practices among injection drug users in Vancouver, Canada: a qualitative study. Harm Reduction Journal. severe harms that arise from assisted injecting. Social structural factors that shape the risks related to assisted injection in the Vancouver context included intimate partner relations and social